~By Rashme Sehgal
With prices of cancer drugs selling at astronomical rates, Dr Sameer Kaul, a leading oncologist working at the Apollo Hospital in New Delhi, along with a dedicated group of doctors has kick-started a drug repository which provides free medicine and financial assistance for thousands of poor cancer patients.
Q. How does your central drug repository for cancer treatment work?
A. Our central drug repository like the Reserve Bank of India for cancer patients. Most of the corporate sector, bio pharmacies and medical devises give us their product free of charge or at nominal rates which we try and disperse in the quickest time.
I emphasise quickest time because people with cancer have little time, it is an evolving disease and one stage progresses into another. The help that cancer patients get from state and central government through their various schemes requires extensive paper work and that takes up a lot of time.
Q. You said cancer is an evolving disease?
A. Patients do not have much time. Cancer in Stage 1 can easily become Stage 2 and by the time the money from the government schemes comes through, the patient’s outlook changes completely. Not so much from Stage 1 to stage 2 but much more from stage 3 to 4. The largest number of patients come in these higher stages which is why it is important to take decisions in the quickest time. Our decision to help a patient is based on the credibility of the doctor recommending the case because we ourselves comprise a team of cancer specialists and can identify the criticality of the need. If there is a patient anywhere in the country whose doctor recommends a patient is in dire states and needs financial help or drugs, then depending on who is making the recommendation and what his credibility is, we take just five minutes to decide on a case. We have kept formality to the minimum.
Q. Why has cancer become such an expensive drug to treat?
A. Today cancer medication can cost anywhere from Rs 5000 a month to Rs 5 lakh a month. The cost of the new cancer drugs is very high even for the developed world where these drugs are being developed. We are also in the business of providing free training for nurses, technicians and general practitioners who are the first people cancer patients report to. We show them what early cancers look like. The idea is that they can pick them up early and refer them to the right place to cut short treatment time.
Q. Aren’t doctors and nurses already aware of what cancers look like ?
A. Not always. Lung cancer can be treated for months on end as TB while lumps in the breast can be thought to be benign. When they are not picked up in time, this impacts the result of the treatment. We also hold technical cancer meets for cancer doctors and patients in order to bring them up to date with changing methods of treatment and also free cancer checkups for those living below the poverty line.
Q. We are often told a cancer epidemic is sweeping the country ?
A. That’s not true. The number of cancer cases has increased throughout the world. This is true for the higher income group , the middle income group and the lower middle income group countries. India belongs to the lower income group.
Populations throughout the world are aging. Population levels have also increased as has life expectancy. Cancers of old age have added to the existing list of cancers. Cancers of the aging, prostrate, oesophagus, colon, gastroenteritis and lung cancers are on the rise. Our recording procedures have also improved. We have a name to the disease for which there was no name sixty to seventy years ago. Countries today including India maintain cancer registries to study demographics and the incidents and prevalence of cancer across India.
Registries also help in the allocation of resources and to plan a line of attack. India needs to improve its recording skills. Cancer is the highest health spend in every country. All countries are not grappling with the issue of affordability. There are not enough monies and even insurance agencies do not have enough money required to adequately tackle this disease. Even richer countries are facing this problem.
In India there is a double whammy. Not only do we not have enough money but our technical infrastructure is yet adequate enough. The distribution of cancer hospitals is not homogeneous and there is a lot of variability in the quality of care. We have to develop standardised cancer guidelines to treat cancer appropriately because we do not stick to schedules and protocols thereby leading to an increase in costs.
I must emphasise that for innovator companies, it can take over $ 5. 2 billion for a pharma company to get a new drug in the market. Our own Indian companies are not up to the mark. We do only copycat research. When a company patent expires, we duplicate and copy the drug. We are not innovators. We do not have money or the temperament. Research is not a prime career option because the reimbursements for research are meagre.
Q. What is the way out?
A. Better models of delivering health care required. We need to work out how much money is spent and what is its outcome. Treatment has to become value for money. We also need to decide whether our thrust should be through centres of excellence or treatment should be taken into the community. The Nordic countries like Norway and Sweden are excellent examples of cancer innovation. Should we have centres of excellence where cancer treatment is developed in one big hospital or spread it out in communities?
Q. What is your view?
A. We need to have both. We must also decide the type of reimbursement for cancer patients meaning should the company take money for the drug when it succeeds in curing a patient or refund money if the drug does not work.
Q. I have never known a drug company reimbursing money because their drugs have failed to cure? You mentioned that a single shot of a newer drug cost $350 to $ 500. How many patients in India can afford to buy these drugs?
A. We need to innovate, to negotiate, to increase access to these drugs in order to understand just how much is required to become an essential part of the treatment plan for a patient. The newer treatments pertain to Robotic Surgery, targeted and personalized enzymes, proteins and immunological agents. These are mostly ill afforded by Middle and Low income populations. Since there are no alternatives to these sophisticated treatments and we generally make do with traditional chemotherapy and Radiation treatments which brings with it a fair share of toxicity.
Q. Just how much of new research is taking place in the field of cancer?
A. We are presently using genomics to treat our patients. By doing so, we use a diagnostic approach to understand the genetic message in a tumour, its DNA structuring and which drug will work for its treatment. Almost like getting a culture test for a urine infection. A urine test tells us what line of treatment to pursue and what is the best antibiotic to give. That is what is happening in cancer. Personalised medicine or disruptive medicine will yield affordability because then you don’t waste drugs .
Q. I still maintain that few Indians can afford drugs at these rates?
A. This is better than doing a hit and miss. This diagnostic approach has succeeded in mice and this approach should work with humans also. We are able to find out the high likelihood of cancer developing and can alter it.
Q. Why would we want to alter this?
A. The genetic message is very important. Testing of women for BRCA 1 and BRCA 2 will help determine her chance of getting breast cancer. You have control over your future. Angelina Jolie got both her breasts removed after her BRCA 1 and BRCA 2 tested positive.
Q. Is cancer also a genetic disease?
A. Most of it is genetic, it is gene linked and 15 per cent of it is hereditary. While 15 percent of all cancers are inherited through familial lineage, 85 percent are termed sporadic. They arise due to mutation in our genes and, internal hormonal disequilibrium.
Q. What about environment linked cancers ?
A. Cancer is a product of both the internal and external environment. Pollution, tobacco, ionising radiation and other known carcinogenics, aniline dyes, constant chemical irritation and HPV/ Epstein bar virus are also caused by our external environment.
Q. As the earth gets more polluted, there are more chances of us developing cancer?
A. Yes, external environment is responsible as also diet and lifestyle. We need to teach children to eat wholesome foods and greens from their childhood.
Q. To go back to the earlier question, just how much cancer health care is available to the poor?
A. Speaking for ourselves, we are only working with the lower income groups. In the private sector, we are probably the only group in the private sector today that gives cancer patients money for eating, staying in a dharmsala, travelling, paying doctors fees and for getting their tests done.
Q. How much do you actually give?
A. The money can run from Rs 5000 a month to lakhs of rupees per month. The medicine costs for leukaemia patients is running into over Rs 60,000 per month.
Q. How do you raise the money?
A. We do not take a single paisa from the government. The money is raised from grateful patients, relatives, philanthropists, social media and through crowd funding.
Q. Families today are running into huge debts while treating cancer patients?
A. Cancer is the commonest sickness ending in medical bankruptcy. That is why the concept of affordable cancer care and outcome based cancer must be developed.
Q. My final question is that despite all the research in this field, we still do not know how we get cancer?
A. It is just an uncontrolled growth of the body cells which disseminate throughout the body. There is an underlying genetic message which is acted upon by different agents called carcinogenics.